HomeMy Public PortalAbout9569 BROADWAY_Sewer__ ;6A6<xo5° APPLICATIO FOR PERMIT , °
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER—SEW GE DISPOSAL
BUILDING AND SAFETY DIVISION FD uoING q �•C `�•
JOHN A. LAMBIE. County Engineer a°oREss / d LL//
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEARE6T
FOR APPLICANT TO FILL IN `"D5B BT.
LEGAL ��TT ''''J�
DESCRIPTION LOT NO.LL� OWNER
MAIL
BLOCK TRAC ADDRESS
NO. OF FLUIDS.
SIZE OF LOT NOW ON LOT CITY • TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP Pfl OC EO BY
BK PG
CONT 'f O
ADDRESS 3 / /CONNECTION D TA
STATION ` . DEPTH
CITY _ TEL I
ATE MANHOLE REFEgENCE
REGISTRATION NO. COUNTY I LOWER
NO. GESCRI PTI ON F WORK E TYPE OF CONNECT IO NGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P.L. LL.TO P.L. /
PUBLIC SEWER U $5.00
SEPTIC'TA NK.SEEPAGE PIT OR / P.C.NO. O
PITS ANO/OR DRAINFIELD ® SIO.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO _ TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSAL SYSTEM S3.00 LJ V
CONNECT ADDITIONAL BLDG,OR I� AFFIDAVIT WAIVER15EY[M RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER 53.00 O
H
OVERFLOW SEEPAGE PIE DRAINFIELD
ALTER.
ESSPOOOR ABANDON HOUSE ® 85.00 W
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING a
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT `*
PERMIT NO,
INDUSTRIAL
WAST APPROVAL
CHARGES
OWNER'S PERMIT s x 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE H REIN NAMED CO. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED %ISTING DWELLING APPROVALS _
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ ��
OWNER OR NEW HOUSE SEWER y
OW REFS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
IELD
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
AL
WITH L COUNTY ORDINANCEE S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS RE HIED BY LOS ANGLES CO NTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AT 1 AM THE LEGAL OWNE OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, T VE OESCR�IBBWR IAL PROPER �yJ�/Y ABANDON HOUSE SEW ER
SIGNATURE Imo/ ®/L gpCKFILL SEPTIC TANKG ❑
OF PERMI //// / ❑
SEEP.PIT ISI ❑ CESSPOOLS
VALIDATI ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK'. M.0. CASH //
q11f
� XIV